Monday, April 14, 2014

Idiopathic Intracerebral Hypertension (IIH)/Pseudotumor: Removing Less CSF Is Best (I9-1.006)

Idiopathic Intracerebral Hypertension (IIH)/Pseudotumor: Removing Less CSF Is Best (I9-1.006)
Neurology recent issues

OBJECTIVE: To establish desired cerebral spinal fluid (CSF) volume removal when using lumbar puncture (LP) as a therapeutic modality in Idiopathic Intracerebral Hypertension(IIH)/Pseudotumor for best clinical outcomes and pain relief.BACKGROUND: While LPs are used in the diagnosis of IIH, they often provide extended headache relief as well. However, low pressure headache soon after LP can be debilitating. "High-normal" closing pressure is considered the goal for best outcomes.DESIGN/METHODS: Outpatient fluoroscopic LPs from 10/2011 through 10/2013 were retrospectively reviewed. Patients had preexisting diagnoses of IIH, or the LP (in clinical context) was diagnostic for IIH. Patient demographics and LP procedure parameters were collected. Post-LP follow-up calls to patients asked whether headache was worse, the same, or better.RESULTS: 41 patients met inclusion criteria, and they were all women. Mean age was 34.3±10.3(standard deviation) and mean BMI was 37.8±8.0. Twelve LPs were performed at L2-3, seventeen at L3-4, twelve at L4-5, and one at L5-S1. Mean opening (OP) and closing (CP) pressures were 29.8±5.8 and 16.2±2.9 cm H2O, respectively. Mean volume removed was 9.9±3.9, and the ratio of (OP-CP)/volume removed was 1.50±0.73. There was no correlation between OP and BMI, nor OP and interlaminar level of LP. Headache symptoms at follow-up were improved in 24 patients, worse in six patients, the same in four patients, and seven patients could not be contacted.CONCLUSIONS: Desired CP in IIH is 15-20 cm H2O, to avoid extended low pressure symptoms, and possible admission or blood patch. Though clinically variable, our data suggests that for every 1 mL of CSF removed, the CP comes down approximately 1.5 cm H2O. To avoid low CP, practitioners should first remove 1 mL for every 1 cm H20 reduction desired, and then recheck pressure. The traditional 20 mL removal for diagnostic LPs may lead to excessive low pressure symptoms.

Disclosure: Dr. Fiorito-Torres has nothing to disclose. Dr. Rayhill has nothing to disclose. Dr. Perloff has nothing to disclose.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/I9-1.006?rss=1

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